- Facility/Professional
- Facility
- Modifier
- 26
- Low / Median / High Price
- $278.11 / $278.11 / $278.11
| Facility | 26 | $278.11 | $278.11 | $278.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.55 / $1,034.55 / $1,606.90
| Professional | | $1,034.55 | $1,034.55 | $1,606.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,001.58 / $2,030.54 / $2,501.96
| Professional | | $2,001.58 | $2,030.54 | $2,501.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.08 / $1,943.48 / $6,682.90
| Professional | | $1,166.08 | $1,943.48 | $6,682.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,416.60 / $2,244.36 / $2,711.84
| Professional | | $1,416.60 | $2,244.36 | $2,711.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,238.58 / $1,636.95 / $1,914.38
| Professional | | $1,238.58 | $1,636.95 | $1,914.38 |
- Facility/Professional
- Professional
- Modifier
- 26
- Low / Median / High Price
- $353.33 / $461.30 / $525.92
| Professional | 26 | $353.33 | $461.30 | $525.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.49 / $1,875.55 / $2,188.14
| Professional | | $1,194.49 | $1,875.55 | $2,188.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,925.00 / $2,264.69 / $2,355.30
| Professional | | $1,925.00 | $2,264.69 | $2,355.30 |